Provider Demographics
NPI:1568689776
Name:KID-1 PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:KID-1 PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:JENNINGS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:520-876-5431
Mailing Address - Street 1:907 E COTTONWOOD LN STE 1
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85222-2226
Mailing Address - Country:US
Mailing Address - Phone:520-876-5431
Mailing Address - Fax:520-876-4875
Practice Address - Street 1:907 E COTTONWOOD LN STE 1
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85222-2226
Practice Address - Country:US
Practice Address - Phone:520-876-5431
Practice Address - Fax:520-876-4875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD45441223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty